Faces First and Treatment Compromise
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The lecture will explore the relationship between the dentoalveloar complex and facial esthetics. Specifically, orthdontic treatment decisions and their relationship with the integumental oro-facial complex will be discussed. A brief historical perspective will be presented and our responsibilities as orthodontists will be highlighted. Particular attention will be given to expansion of the dental arches and the subsequent effect on the esthetics of the facial complex. Learning Objectives: - Incorporate time tested facial analyses into their diagnostic regimen. - Recognize the need for a differential diagnosis when treatment planning. - Visualize facial compromises when choosing treatment mechanics.
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Faces First and Treatment Compromise
- 1. I, the undersigned, declare that neither I nor any member of my family have a financial arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing education presentation, nor do I have a financial interest in any commercial product(s) or services I will discuss in this presentation. Dennis M. Ward D.D.s., MsD.
- 3. Dr. Dennis M. Ward *34 years private practice Avon Lake, Ohio *Clinical Assistant Professor Case Western Reserve University *Adjunct Faculty Seton Hill University *
- 5. “…for each of his efforts, whether he realizes it or not, makes for beauty or ugliness; harmony or inharmony; for perfection or deformity of the face.” E. H. Angle, 1907
- 6. Desmond Morris, “Manwatching: A Field Guide to Human Behavior”, 1979
- 9. Orthodontic Diagnostic Responsibility 3. Facial 1. Skeletal 2. Dental
- 10. Ricketts E Line Steiner’s S1 Line Burstones’s B Line Sushner’s S2 Line Holdaway’s H Line Buschang,P.H., Fretty K., Campbell P.M., Can commonly used profile planes be used to evaluate changes in lower lip position, The Angle Orthodontist, Vol 81, No 4, 2011 pp 557-563.
- 12. Description In Lateral Aspect Concave Straight Convex
- 14. Nasolabial Angle Well BalancedObtuse Acute
- 15. Facial Esthetics in the Literature 9,287 References to Facial Esthetics In the Orthodontic Literature
- 16. “Full Lips”…………………What does that mean? Full Lips Defined in The Literature: Zero
- 17. What Does Full Lips Mean?
- 18. “ It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so’” Mark Twain
- 20. This This
- 21. 21 “Anything out of proportion is always a non-harmony. To achieve the proper proportions is a goal for existence and life…it is fundamental not only to art and design, but to all creation.” … An “Art is an endeavor towards perfection.”
- 23. The Potter Stewart Test “I know it when I see it.”
- 24. Orthodontic Treatment Planning is a Compromise Our Challenge is to Find The Most Favorable Compromise for Our Patients
- 26. Functional Matrix Facial Growth and Development Dr. Melvin Moss Dr. Donald Enlow
- 27. Hypertonic Mentalis Everted and Bulbous Orbicularais Oris Zygomaticus Major Zygomaticus Minor Risorious Levator Labii Superioris Depressor Labii Inferioris Depressor Anguli Oris
- 28. Exercise
- 29. With the new orthodontic paradigm of developing the arches and placing a palatal expander as a birthright of passage…have we ignored our responsibility to FACIAL ESTHETICS.
- 31. Drs. Mark E DeMaria, Donald Rinchuse, Daniel Rinchuse and Thomas Zullo “Mouth Frown Arcs” – Dental and Skeletal Characteristics Mouth Frown Arc: The lips at repose are turned down at the commissures.
- 33. Well Balanced Proportional Profile Outstanding Symmetry Treatment Choice: Second Bicuspid Extraction Protocol
- 34. DT Treatment Quadrangle Dr.Stephen McCullough Yukon, Oklahoma
- 35. Well Balanced Proportional Profile Outstanding Symmetry Treatment Choice: Non Extraction Protocol
- 37. DT AP
- 38. DT
- 39. AP
- 40. DT AP
- 45. “…for beauty or ugliness… …for harmony or inharmony…” It’s Our Responsibility
- 46. How do we do it? •Control the Vertical Dimension •Control the Occlusal Plane •Work within the Treatment Quadrangle
- 47. Anchorage Preparation * Tipping the mandibular posterior teeth distally to a predetermined angulation relative to the occlusal plane.
- 49. Crowding Anterior Area 5.11mm Mid Arch Area 3.86mm Posterior Area 13.44mm Total Crowding 22.41mm
- 50. PY FMIA 58.1 FMA 26.9 IMPA 95 SNA 82.6 SNB 78.6 ANB 4.1 AOBO .7mm OP 9 Z 71.9 UL 9.1mm TC 9.7mm FHI .76
- 51. PY FMIA 58.3 FMA 26 IMPA 95.7 SNA 80.9 SNB 77.6 ANB 3.3 AOBO 2.8mm OP 10 Z 72.8 UL 12.4mm TC 11.4mm FHI .77
- 52. PY
- 53. PY Treatment Quadrangle FMIA 58.1 FMA 26.9 IMPA 95 Z 71.9 OP 9 FMIA 58.3 FMA 26 IMPA 95.7 Z 72.8 OP 10
- 54. PY *Maxillary Vertical Dimension Maintained *Maxillary Incisors Retracted *Mandibular Molars Moved Anterior *Mandibular Vertical Dimension Maintained *Mandibular Incisors Maintained *Occlusal Plane Maintained
- 59. NW FMIA 68.9 FMA 24.3 IMPA 86.7 SNA 87.5 SNB 85.6 ANB 2.0 AOBO -1.8 OP 8 Z 78.5 UL 15.8mm TC 11.0 mm FHI .76
- 61. Crowding Anterior Area 5.0 mm Mid Arch Area 2.35mm Posterior Area 22.13mm Total Crowding 29.47mm 7.23
- 66. NW FMIA 71.9 FMA 24.7 IMPA 83.4 SNA 86.9 SNB 86.2 ANB .7 AOBO .8mm OP 9.2 Z 82.8 UL 15.mm TC 15.8mm FHI .81
- 67. NW Treatment Quadrangle FMIA 68.9 FMIA 71.9 FMA 24.3 FMA 24.7 IMPA 86.7 IMPA 83.4 Z 78.5 Z 82.8 OP 8 OP 9.2
- 68. NW
- 70. Final Thoughts…………. * Our Obligation to Facial Esthetics is Absolute * Individual Diagnosis is Key
- 71. •The Future of Orthodontics… • …is Ours to Define
- 73. Special Thanks Dr. Sofia Xofylli Dr. Stephen McCullough
- 74. Thank you!
Editor's Notes
- Id like to thank the American Association of Orthodontists for honor of presenting material at this the 2017 Meeting
- In 1907 Dr. Edward Hartley Angle penned perhaps the most significant two paragraphs in the history of our specialty. “ The study of Orthodontia is indissolubly connected with art as related to the human face. The mouth is a most potent factor in making or marring the beauty and character of the face, and the form and beauty of the mouth largely depend on the occlusal relations of the teeth. Our duties as orthodontists force upon us great responsibilities, and there is nothing in which the student of orthodontia should be more keenly interested than in art generally, and especially in its relation to the human face, for each of his efforts, whether he realizes it or not, makes for beauty or ugliness; harmony or inharmony; for perfection or deformity of the face. Hence it should be one of his life studies.
- So in a very brief 20 minutes I’d like to exam one segment of that profound statement.
- In 1977, Desmond Morris published a book called Manwatching. A human social biologist, Morris studied human behavior. In one such study…. We can see, 70 years prior to Morris’ publication, Dr. Angle charged us with the responsibility of protecting and enhancing the human face.
- Orthodontic diagnosis and treatment planning are an exercise in biologic juggling. We have to balance Function… (a cuspid protected occlusion)…Stability…( It better last, God forgive if a lower incisor rotates)…and Esthetics both dental and Facial
- All too often, for whatever the reason. Like my Cleveland Browns we have dropped the ball when it comes to our responsibility to Facial Esthetics.
- Perhaps the single most important thing that will set us apart is or recognition and acceptance of our role in treating not only malocclusions….but the face as well
- We have numerous ways of evaluating facial form the lateral aspect.
- Personally I use Dr. Levern Merrifield’s Z angle. The key is not what you use to evaluate the soft tissue….its actually using something consistently!
- We have language that can describe the lower third of our face.
- We all recognize symmetry and proportion..One need only look at the case write ups for the ABO
- The problem is not in the description…we can do that great…the problem is in doing something about it.
- Our literature is abundant with references to facial esthetics. Giants in orthodontics…Angle..Tweed….Peck and Peck…Ricketts…Drs.Klontz and…Noffel..sitting right here… and numerous others have written exhaustively about our role in maintaining and improving facial balance. Indeed at this very meeting, the author of one of the earliest and most exhaustive pieces on Facial Esthetics, Dr. Sheldon Peck, is receiving our highest Award…The Ketchum Award… if you get the opportunity thank him for his contribution……
- Obviously human perceptions change over time. Profiles and facial balance that were once desirable in the 1940’s and 50’s may not be as readily desirable today. Indeed slightly more convex profiles are the recognizable social norms. In many of our most recent literature the conclusion is ‘…we like fuller lips..” But….ClICK There is no definition of what that means.
- By stating “ I like fuller lips”….does not abdicate the orthodontist from his responsibility to Dr. Angle’s challenge. Indeed this one statement maybe responsible for everyone and anyone sticking braces on teeth and proudly proclaiming…They Do Orthodontics….Heck you don’t even need a dental license anymore…just a Walmart or Costco card.
- Mark Twain stated…..
- By placing appliances and climbing the archwire ladder pushing teeth forward does not create this. Orthodontics created this….Mom and Dad this
- These two are not equal.
- If we turn to the literature on art we find these two quotes….
- Is our perception of beauty as simple as this…..who do we like better, Wilma or Betty?
- Perhaps or only valid assessment of beauty is to apply the Potter Stewart test. Justice Potter Stewart when ruling on obscenity said he really couldn’t define it but he knows it when he sees it. If it is as simple as that then our responsibility to facial esthetics CLICK SLIDE becomes that much more important.
- Everything we do in orthodontics is a compromise….Many times we have to decide which is the best compromise for the patient. All too often what mechanics that help us line up teeth….is ultimately destructive to facial balance.
- We have to realize that what we do here CLICK SLIDE has an effect here, which has an effect here CLICK SLIDE. Our perception of attractiveness is judged from the frontal aspect. No one, including orthodontists, have ever approached there significant other by evaluating their profile line.
- We do not move teeth in a vacuum . Dr. Melvin Moss and later Dr. Donald Enlow spoke of the relationship of what they termed the functional matrix. CLICK SLIDE All the investing tissues that encompass the maxillo-facial complex
- Our area of expertise and mechanical manipulation is surrounded by a network of coordinated soft tissue that defines our emotions, temper and character. Just because we push some teeth around doesn’t alter the functional matrix or change our DNA
- Repetitive contraction and expansion of the thin and thick filaments found n skeletal muscle causes a noticeable increase in definition of the muscle. The muscle itself becomes much more visible as the epidermis is stretched
- The question is…..are we doing this to our patients? The muscles of facial expression and mastication are no different from the bicep or tricep.
- By pushing teeth forward. The perioral musculature can no longer remain passive when the lips are in repose. The constant contraction and relaxation , exercise, causes an increase in the definition of the individual muscles. Now if we apply the Potter Stewart test….I think we can agree that multiple phases of orthodontics has not left this young woman better off.
- In an article recently the authors defined “Mouth Frown Arcs”. The study tried to relate the underlying skeletal pattern to the outward appearance of a frown. Although they did not find any correlation to a given skeletal pattern, the literature review revealed a great deal about socio-biologic perceptions of our face
- Over a 12 week period parents of patients were asked to look at a photo and write down any emotional or perceptions about the face portrayed. The photo on the left was presented for the first six weeks and the photo on the right the second six weeks. The top 5 responses were the following. As Dr. Angle aptly stated we have “..great responsibilities…”
- So lets look at two similar cases…The first case Donna….
- Dr. Steve McCullough calls this the treatment quadrangle, this is where we work. Dr. Lysle Johnston once called the occlusal plane our workbench. These two descriptions aptly describe our area of expertise. Managing teeth along the occlusal plane within the treatment quadrangle is the only thing that will separate the specialist from the wanna be.
- Ashley as well has….
- As we can see on inspection very similar patients. Both had similar amount of crowding, Donna 9 mm and Ashley 8mm in the anterior teeth
- Looking closely at the quadrangles….
- How do we control the vertical? Tads, Meaw technique..Loyd pearson FB
- The easiest and most consistent way is through anchorage preparation.
- Let’s look at two cases quickly in a little more detail. This is Payton a 14+ year old
- Our Obligation Facial Esthetics is Absolute Individual Diagnosis is Key
- We are at a very historical time in orthodontics. The choice is ours to make. We are at a decisional crossroad. Do we continue to tout ourselves as just better at putting braces on or do we emphasize the skills that make us Specialists.
- 110 years ago Dr. Angle challenged the fledging specialty to reach higher. The choices of harmony or inharmony, beauty or ugliness and perfection or deformity are still relevant…and will ultimately define us
- Again I would like to thank the AAO for this opportunity and to you all for putting up with me… I’d also like to challenge our leadership to take to heart the words of Dr. Angle.